Vulnerability to Psychosis: A Psychoanalytic Study of the Nature and Therapy of the Psychotic State

'Franco De Masi is well known for his psychoanalytic work with patients suffering psychotic illnesses. In this book, he addresses the human vulnerability to psychosis, but the modest title of his book belies the depth of its investigations and conclusions. De Masi invites the reader into a thoughtful, systematic exploration of many aspects of the complex problems associated with psychotic illnesses: its ontogenesis and the emotional crises that lead to the dominance of psychotic thinking, the function of psychosis with regard to reality, its eruption or progression (depending upon the type of psychosis involved) and, crucially, the difficult and painstaking task of treatment. This latter theme is explored in considerable detail and is perhaps the most telling message of this book. Example after example of de Masi's engagement with patients illuminates his central objective - the gradual disinvestment by the patient of psychic energy allocated to ostensibly protective, but ultimately self-destructive, psychotic constructions and a re-investment in neurotic or more normal psychic reality - a world the patient has had to largely forsake under the sway of delusion... This book is large in scope and substantial in content. It provides the clinician with important perspectives on the origins and development of delusions in psychosis and offers a new perspective regarding the radical differences between delusional and normal or neurotic thought, and how these differences come about. It moves our thinking forward in an area that has too often been neglected, and for this we need to be grateful.'- Paul Williams, from the Introduction

“Analysts have to admit that where quantitatively massive upheavals of the personality are concerned, such as in the psychoses, the purely psychological methods by themselves are inadequate and the organic and chemical means have the advantage over them”

(A. Freud, 1968, p. 131)

The analytic model

Biological models postulate that psychosis stems from a genetic vulnerability that is expressed in structural or biochemical alterations of the central nervous system. By investigating the symptoms—manifestations of underlying organic changes—we can seek out and identify the biological defect that lies upstream of them.

According to psychological models, on the other hand, the symptoms are the expression of a psychic dynamic whose originscan be traced back to the patient’s current or childhood relationships. The psychoanalytic view is that the reasons for mental disorders are unconscious; thus, psychoanalytic investigation is based on a general theory of psychopathology and follows an eminently individual path. Psychoanalytic theory itself stems from in-depth study of a small number of individual clinical cases, which, however, allowed the development of general theories of mental functioning. Based as it is on clinical experience, psychoanalysis proceeds through theories that are open to modification in time, with new paradigms replacing and supplementing earlier ones. In this respect, it is no different from other disciplines whose theories are subject to verification and change.

But the more we advance in our understanding of psychoanalytic problems, the more, I believe, we become impressed with the importance of the deeper problems of deficiency and deformation of the psychic structures themselves … If the authors had taken these issues more fully into consideration … they would probably would have written a vastly different chapter on the psychopathology of the psychoses in that case

(Loewald, 1966, p. 435)

Regression and primitive mental states

Analysing the psychotic state of Senatspräsident Schreber, Freud (1911c) states that the crucial factor in the construction of his delusion was the libidinal regression triggered by the infantile homosexual conflict with the father. Freud invokes the psychosexual model, according to which illness represents a return to a preconstituted fixation point. His view that the primitive (the fixation point) and the pathological (delusion) were equivalent prevailed for many years in psychoanalytic theory.

For Melanie Klein, too, psychological growth was characterized by the transition from the primitive forms of thought of the paranoid-schizoid position to the more developed modes of the depressive position. She further suggested that some individuals never succeeded in overcoming paranoid-schizoid functioning: any child with particularly intense basic anxiety and aggression was more predisposed to psychosis in later life. Indeed, Klein believed that all children passed through a psychotic phase, but that only a few overcame it completely.

“As he lay wide awake, vast processions passed in mournful pomp before his eyes, and a never-ending succession of ancient, ceremonial buildings soared skyward. Yet soon his day-dreams merged into those of night, and everything his gaze conjured up in the gloom lived again as he slept, in uncanny and unbearable splendour…. Each night, he would plunge headlong into sunless chasms of unimaginable depth, from which there could be no hope of return. Even when awake once more, he remained a prey to all-consuming sadness and despair”

(Baudelaire, 1860, p. 208f., translated)

The psychotic journey

Psychosis can be thought of as a “journey” characterized by specific developmental phases involving the triggering of processes leading, once set in motion, to mental explosion. At first, the patient retains a degree of awareness that he is ill, but this is gradually lost. Entry into the psychotic state is merely theend result of a slow process of transformation: the alterations in the perceptual apparatus and in the consciousness of the self that take place silently over the course of time eventually become visible even to an outside observer. Psychosis may appear clinically as early as in infancy when bizarre behaviour or learning difficulties might signal a process already under way.

“I began having what I don’t think are dreams, since they were not like any dream I have ever had, or read of …”

(Philip Dick, from an interview withUrsula Le Guin, July 1986; in Sutin, 1989)

“At that time almost the whole of my life was not experienced as such but as a film or as a reflection of the film projected by my mind on to the screen of my unconscious. Unfortunately, the unconscious can only feel and does not see, just as the eyes can only see and do not feel, and because the unconscious does not have eyes of its own to see inside, into its fantasies, but can only feel itself, it sees the internal images as delusions outside through eyes it lacks inside.”

These words were written to me a year after the end of a patient’s analysis and refer to the memory of the psychotic state that had dominated the analytic picture for a long period. What was the patient telling me? Why was he talking about the unconscious that had no eyes to see inside itself? Which unconscious was he referring to? His words seemed to me to provide a suitable opening for this chapter on the unconscious, whose aim is to examine some of the relations between analytic theory and psychosis. I contend that, by starting from the study of the unconscious, we can clarify the difference between neurosis and psychosis and construct an analytic approach more suitable for the latter condition.

“The god created dreams to show the way to the dreamer, whose eyes are in darkness”

(Egyptian Papyrus Insinger)

Imprisonment in psychosis

The Schizophrenia Bulletin of the US National Institute of Mental Health includes a section, “First Person Account”, open to patients and their families. In some of these articles, patients diagnosed as psychotic discuss the way they live and their problems. (A collection of accounts by these patients and members of their families has been published in Italian by Bertrando [1999].) One of these descriptions seems to illustrate particularly well the state of mental imprisonment in which some patients live even when they have succeeded in recovering a part of their social capacity.

The patient concerned writes:1

“Over the years I have had many‘mad’ thoughts, but my main delusions, of grandeur—mediumistic phenomena—and persecution, have remained constant. These delusions are supported by such vivid hallucinations that I cannot usually distinguish them from reality, except by saying to myself that none of this is real, that what the people I love and trust tell me is true, that I am unusual only because I am schizophrenic, and that everything I think about the supernatural is due to an illness.”

“Perhaps this is the bottom line to mental illness: incomprehensible things occur; your life becomes a bin for hoax-like fluctuations of what used to be reality…. The madman experiences something, but what it is or where it comes from he does not know”

(Dick, 1981, p. 26)

In this chapter I shall attempt to describe the progress of a hallucinatory state that developed during the course of an analysis and to illustrate how the patient’s self was recomposed in a process whereby his confusing and destructuring superego evolved into one that was more characteristic of melancholia. In the course of my exposition, I shall describe the psychic experience resulting from the action of the psychotic superego, involving, for example, condemnation, accusation, and mental terror, and I shall show how the process of recovery was thereby impeded.

I shall, therefore, tell of the road travelled by the patient in order to emerge from the psychotic state, the obstacles overcome, and my own frequent moments of difficulty and loss of bearings; finally, I shall consider the constant recourse by patient and analyst alike to the analytic method as the only possible therapeutic approach.

“Schizophrenia cannot be understood simply in terms of traumata and deprivation, no matter how grievous, inflicted by the outer world upon the helpless child. The patient himself, no matter how unwittingly, has an active part in the development and tenacious maintenance of the illness and only by making contact with this essentially assertive energy in him can one help him to become well”

(Searles, 1979, p. 22)

Spider

David Cronenberg’s film Spider, which is based on Patrick McGrath’s identically titled novel (McGrath, 1990), tells the story of a schizophrenic, nicknamed Spider by his mother, who is sent to a halfway house after being discharged from the psychiatric hospital where he has been a patient for twenty years. On leaving the hospital to return to normal life, Spider is fearful, withdrawn, and suspicious of the world around him; he moves about like a zombie, as if lacking any awareness of himself and others.

The halfway house where he is to live is situated in the district on the edge of town where he spent his infancy. So he is able to revisit the house where he lived as a child, the canal and the gasholder, the little garden, and the pub where his father was a regular. The reconstruction of his past is central to the unfolding of the film’s plot. Everything Spider sees brings back memories of his infantile years.

“Delusional production positions itself in a space that is neither the inner space of the psyche, nor external space, and not even intermediate or transitional space …. Does this mean that delusional people are the inventors of a fourth space? It must be agreed that delusion cannot be limited to its manifest or latent meanings. Delusion has a way of placing itself in its own space—that is, of secreting a space of its own”

(Racamier, 2000, p. 823-824, translated)

Mackey: How could you … a mathematician, a man devoted to reason and logical proof … how could you believe that extraterrestrials are sending you messages? How could you believe that you are being recruited by aliens to save the world? How could you …?

Nash: Because … the ideas I had about supernatural beings came to me the same way that my mathematical ideas did. So I took them seriously. [Nasar, 1998, p. 11]

The above passage is quoted from a conversation between Professor George Mackey of Harvard University and John Nash, a Nobel prizewinner and eminent mathematician who became psychotic, and whose disconcerting life was reconstructed in the film A Beautiful Mind. Although cast in the sickly-sweet Hollywood mould, this film, which has a certain fascination of its own, can help us to understand how delusional imagination and intuitive imagination seem identical to a person who experiences delusion.

“I realize now that, in the past, I was like a man who, having at first denied the existence of light, made himself blind to the objects which it nevertheless illuminated. I have unfortunately had to realize that I experienced nearly all of my external life not as such, but as a film, or as a mirror of the film which my mind projected on to the screen of my unconscious”

(From a letter written by a psychotic patient afterthe end of his analysis)

Misunderstanding and the analytic impasse

Afundamental aspect of analytic work, in my view, is the patient’s capacity to apprehend and explore the analyst’s mental functioning and to interact with it. This experience may develop by way of correct perceptions or under the influence of past traumas or primitive objects that inevitably alter the image of the analyst. The two elements are often present simultaneously. When the analyst systematically distorts the patient’s communications, this usually gives rise to a blockage in the analytic process, which is commonly referred to as an impasse. As a rule, the patient will signal his difficulty to the analyst soon after this situation arises, and it is essential for the analyst to accept this communication and turn it to account.

“If it is to be possible for an analyst or a mental hospital to cure a schizophrenic patient it must certainly be possible for a mother to do so while the infant is right at the beginning, and the logical conclusion is that the mother often prevents schizophrenia by ordinary good management”

(Winnicott, 1987, p. 45)

As we know, Freud considered that psychotic patients were not amenable to psychoanalytic treatment because they were unable to develop a transference. Abraham (1912), on the other hand, was convinced that the transference existed even in schizophrenia. Other analysts, too (among others, Ferenczi, Federn, Sechehaye, Sullivan, Fromm-Reichmann, Searles, Rosen-feld, Aulagnier, and Benedetti), have expressed the conviction that conditions useful for the therapeutic process can be created even with psychotic patients.

In Abraham’s view, the need, in cases of narcissistic neurosis (i.e., schizophrenia), is to seek actively to maintain a relationship with the patient by taking advantage of the positive transference; ifthe transference were to be analysed, as in the therapy of neurotic patients, the analytic process would be disturbed.

“Oblomov’s face suddenly flushed with happiness: his dream was so vivid, so distinct, and so poetical that he at once buried his face in the pillow. … His obliging imagination carried him lightly and freely into the far-away future

(Goncharov, 1858, pp. 81 and 82)

“Once Chuang Chou dreamed that he was a butterfly. He fluttered about happily, quite pleased with the state he was in, and knew nothing about Chuang Chou. Presently he awoke and found that he was very much Chuang Chou again. Now, did Chou dream he was a butterfly or was the butterfly now dreaming that he was Chou?”

(Chuang-tzu, quoted in Blechner, 2001, p. 239, inthe chapter entitled “Knowing what we know inwaking and dreaming”, and also in Borges, 1976)

This tale is a good introduction to some considerations on the nature of delusion, the central core around which the ther-T apy of psychosis revolves. In the waking state, how can we know whether we are perceiving something real or instead creating an object with our imagination? What helps us to differentiate reality from fantasy creations? A clinical vignette drawn from the initial interview with a twenty-five-year-old patient who used soft drugs will be useful for illustrating the clinical problem I wish to discuss.

“A man who wants to lose his self discovers, indeed, the possibilities of human existence, which are infinite, as infinite as is creation. But the recovering of a new personality is as difficult—and as hopeless—as a new creation of the world”

(Arendt, 1943, p. 63)

In this chapter I shall consider one of the fundamental aspects of the psychotic process: the transformation of identity that takes place during the course of the illness. This transformation has particular characteristics. The patient perceives that he has a new identity, with in some cases ideal, and in others frightening, traits, or that he has become someone else—a character of his own fantasy—but is unaware that he himself is responsible for this transformation. The new delusional identity appears to him as a revelation, as an incontrovertible truth that casts new light not only on the present but also on the past, which is revisited and adapted to match the new version of the facts.Yet, this statement is only partially true, as a psychotic patient partly retains the perception of his lost identity. It is rather like Gregor Samsa in Kafka’s “Metamorphosis”, who perceives that he has been transformed into a monstrous insect, but “knows” that he is still Gregor Samsa.

“The aetiology common to the onset of a psychoneurosis and of a psychosis always remains the same. It consists in a frustration, a non-fulfilment, of one of those childhood wishes which are for ever undefeated and which are so deeply rooted in our phylogenetically determined organization”

(Freud, 1924b, p. 151)

This chapter is concerned with the complex relationship between trauma and the psychotic state. After examining infantile emotional trauma as an experience conducive to the onset of illness in adult life, I shall discuss the traumatic effect of psychosis on the psyche, and, last, describe the inability to tolerate frustration in the psychotic state.

Emotional trauma

Piera Aulagnier (1975) links psychotic illness to maternal violence, the violence practised in normal circumstances by a mother on herchild to structure his reality sense. In the case of a psychotic patient, excessive violence has the effect of an intrusive action that creates an object with the same characteristics in the child’s mind. To rid himself of the pressure of the intrusive object, the child must construct a self-representation contrary to the mother’s will by violent methods. The violence inflicted by one mind on another is repeated in the analytic process: the patient feels compelled to believe in his delusion, and the analyst likewise feels invaded by a distorted and alien kind of thinking.

“People kept thinking I was regaining my brilliance, but what I was really doing was retreating to simpler and simpler levels of thought”

(The words of Lawrence, a young schizophrenic,quoted in Nasar, 1998, p. 295)

The bat

In a classic paper entitled “What is it like to be a bat?”, the philosopher Thomas Nagel (1974) writes that, if we try to imagine how being a bat must feel to a bat, we notice that our mind’s resources are not equal to this task. Since every mental phenomenon is essentially bound up with one’s personal point of view, it is not possible to imagine what the consciousness of self of a subject other than ourselves must be like. Nagel is not claiming that we cannot know what it is like to be a bat, but that, in order to obtain an idea of what it is like to be a bat, we must adopt the viewpoint of the bat. My purpose in citing Nagel is not so much to emphasize the intrinsically subjective character of every mental phenomenonas to draw attention to the distance between our subjective experience and that of a psychotic patient, the “bat”.

“But there is much we can do in future. It is only by understanding our problems, difficulties, and failures in treating schizophrenia and other psychotic conditions that we can gradually achieve greater success”

(Rosenfeld, 1997, p. 23)

Ihave sought in this book to make clear my conviction that the difficulties experienced in the treatment of psychotic patients are due not only to our individual professional limitations, which in any case emerge in the constant process of comparison with colleagues, but also to the intrinsic incompatibility of the psychotic state with the traditional analytic approach. This situation discourages many analysts from taking patients with these symptoms into therapy.

My own view, however, is that as analysts we are in a privileged position: that of listening, session after session, to a psychotic patient who continues to place his trust in our method. No other clinician has the same opportunity of learning directly from someone, like a patient with this pathology, who has entered the worldof psychosis and can help us to understand it. On commencing the therapy of such patients, we should first and foremost bear in mind the need to forget the route followed by the “average” analysand, and instead prepare ourselves for an unpredictable analytic development, often interspersed with crises that may cause the treatment to be broken off. Sometimes these very crises can prove useful, because they compel us to turn back and try to understand what we have failed to comprehend. When the therapy is broken off, as frequently occurs in such cases, this provides us with an opportunity of gaining further significant knowledge.